Backgrounder
Backgrounder
According to the President’s New Freedom Commission on Mental Health, “evidence-based practice is the integration of best research evidence with clinical expertise and patient values.[1] ” The goal of these treatment approaches is to ensure the best mental health treatments and services for people with mental illnesses and their families.
Although evidence-based practice is not a new approach to treating many chronic illnesses, it is new to mental health. In fact, its emergence in the mental health field can be directly linked to the Surgeon General’s 1999 Report on Mental Health. And, it appears to be gaining popularity because it compliments recent calls for accountability in mental health service delivery.
Evidence-based practice, of which evidence-based medicine is one piece, is a promising concept. It can be as reliable and scientific in the treatment of mental disorders as it is for other chronic illnesses. And when applied appropriately, it can increase accountability, improved quality of care and patient outcomes and bridge the existing gap between research and practice.
However, there are challenges to implementing evidence-based practices and concerns regarding the integrity of specific programs and policies labeled “evidence-based.”
Some treatments and interventions may not yet have as deep an evidence-base as other approaches although they offer quite a bit of promise and seem to work. Eliminating access to these treatments and services because they do not fit into the “evidence-based” category would only serve to deny people treatments they need.
Evidence-based approaches can be misused solely as a mechanism to control cost. Specifically, many states and payors market fail first programs, or step therapy, as “evidence-based.” These policies merely restrict access to treatments by forcing people to "fail" on one or more treatments, like medications, that the state or payor sanctions as “preferred” before being allowed to access newer, more effective treatments. And research shows that each individual reacts differently to treatments. So, people with mental illnesses need access to a wide range of treatments in order to live, work and learn in the community.
Many “evidence-based” approaches are not implemented with fidelity to the original programs, or they may focus on only one piece of the “evidence.” For example, mislabeled “evidence-based” approaches often focus solely on symptom reduction scientifically, but not at clinical experience and patient outcomes.
Decisions regarding the criteria for “evidence-based” are oftentimes made behind closed doors without the input of stakeholders or consumers. It is also unclear what evidence is included when dubbing a program or policy “evidence-based” and what is not. All available evidence should be included. In addition, the quality and breadth of the research is often inadequate in that some populations are underrepresented in the evidence. For example, people of color are often not adequately represented in clinical trials, so a full understanding of how culture affects certain therapeutic approaches and how medications are metabolized differently.
Restricting access to treatments and services, either by misrepresenting a cost-saving measure as “evidence-based medicine” or limiting care to only “evidence-based practices,” is harmful to both people with mental disorders and to the economy.
Despite the fact that mental illness is very treatable with the right access to treatments, only one-third of the 54 millions Americans with mental illness receive any treatment at all [2]. This failure to provide the mental health services people need causes long-term and unnecessary suffering, as well as a considerable strain on the U.S. economy.
- Each year, $113 billion is wasted on untreated mental illness - $105 billion of which can be attributed to lost productivity alone[3].
- Recent state health care cutbacks have lead to upsurge of people with mental illnesses seeking care in emergency rooms - a much costlier source of treatment. The mental health treatment received in ERs is not only less appropriate than care received in the community, but the burden on ERs has caused a negative affect on the care of all emergency room patients [4].
- People with mental illness who do not have access to care increasingly find themselves warehoused in America’s prisons, jails and juvenile justice facilities. In 1998, an estimated 283,800 adult offenders with mental illness were incarcerated in the nation’s prisons and jails[5].
- Many victims of a poorly funded and neglected mental health system become desperate enough to take their own lives. In fact, more than 90 percent of people who commit suicide have a diagnosable mental disorder [6].
- President’s New Freedom Commission on Mental Health, Final Report to the President. p. 68, 2003.
- Mental Health: A Report of the Surgeon General, 1999.
- Rice, P. Dorothy &Leonard S. Miller. Health economics and cost implications of anxiety and other mental disorders in the United States. British Journal of Psychiatry; 173(34): 4-9, 1998.
- National Mental Health Association et al. Psychiatric Emergencies Survey. April 2004.
- U.S. Department of Justice, Bureau of Justice Statistics Special Report: Mental Health and Treatment of Inmates and Probationers. July 1999. NCJ 174463.
- The Center for Mental Health Services, National Strategy for Suicide Prevention branch: Mental Illness and Suicide – Facts. www.mentalhealth.org/suicideprevention/suicidefacts.asp.
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